05020134-FJ
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CUPEKrINO
CITY OF CUPERTIl`.
PERMIT APPLICATION FORM —b
APN #
Fee Description
Fee Group
BAPPLOTHER
Building Address: Mailing Address (if different from building address):
r v 6(S %/„, GLJCL e5�
Owner's Name:
Phone #:
ASN
(4—af-) >j-- aS 72
Contractor:
License #:
ai^u- LL l
Boiler > 500K to 1M Btu
Contact: Phone:
Cupertino Business License#:
Fax:
MECHANICAL
Building Permit Info:
Boiler > 1.75M Btu
Bldg Elects Plumb Mech LTJ
Job Description: (roH,L j K -M) 14, Yz 6,,Tk e j 1 66,1.) r- t) 01T ock—
1Commercial
Residential (Apoi) p, ❑ ;,,,;�nw
Sq.Ft. Floor Area:
$/Sq.Ft.:
ties
BUILDING
Cost of Project:,
Occupancy Grou :
BUILDING
BCONSTAXH
Type of Construction:
Please check this box if the project is a
BCONSTAXR
second -story addition: ❑
Project Size: Standard Large ❑ Major ❑
BELEC1000
Quantity Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BBOILERI
Boiler <= 100,000 Btu
MECHANICAL
BBOILER2
Boiler > 100K to 500K Btu
MECHANICAL
BBOILER3
Boiler > 500K to 1M Btu
MECHANICAL
BBOILER4
Boiler> 1M to 1.75 M Btu
MECHANICAL
BBOILER5
Boiler > 1.75M Btu
MECHANICAL
BCONSTAX
Construction Tax
BUILDING
BCONSTAX
Ind/Off/Comm/Quasi
BUILDING
BCONSTAXBQ
Con. Tax for BQ Zone
BUILDING
BCONSTAXH
Hotel and Motel
BUILDING
BCONSTAXR
Constax — Resi/Mobile
BUILDING
BELEC1000
Elec 600V <= 1000A
ELECTRICAL
BELEC1001
Elec 600V > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee t
BUILDING
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Ul'1'x OF CUFER111VU
BUILDING DIVISION PERMIT
10615 JOHN
OWNER'S NAME:
PHONE:
STEVEN CHU & HOSANNA HO
€',) la i - o s 73
ILICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code. -and my license is
in full force and effect. 22 c7K"/ 2 6 -
License
License Class r, Lic. #
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to iLs issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Businessand Professions Code) ur
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law docs not apply to an owner of
properly who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
Z:) 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law docs not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractor's
License Law.
I am exempt under Sec. , B & P C for this reason
Owner li 1 f� eco I'/, Li Date -4 1 " - r
WORKER'S CO ENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPT)ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued. 1 shall not
employ any person in any manner so =`orrl�ub„ject to the Workers' Compensation
Laws of California, Date , // S
Applicant f ta, 02— C N 4
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency I'or the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
Lenders Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCEjR GULSATIONS, - --
f"� 3-
Signature of ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)?
C Yes dNo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants_ as defined by the Bay Area .Air Quality Management
District?
❑ Yes /❑ No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently hate a tenant that it is my responsibility to nosily the occupant of the
rcquiremenL5,whidh must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date
STEVEN CHU & HOSANNA HO
PERMIT NO.0 5 02 013 4
PERMIT ISSUE DATE
08/10/2005
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT— PLIIMRi
Job Description
ADD 1300' -FAMILY RM/ -1..-1/2 BATHRMS
PARTIAL REMODEL/WINDOWS
1 Sq. Ft. Floor.Area ,Valuation
$160000
Nu
Issued by:
Re -roofs
Type of Roof
Required Inspections
pancy "type
Date %S'/ /o
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
►WNER-BUILDER VERIFIC 'ION
1. (Check one) I or my immediate family (parent, spouse or child) will perform
A. k_� All the work authorized by this permit
B. A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City
Phone #
State License #
Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
PersorVFirm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner -Builder Information (reverse side).
Property Owner's Signature: Date: Ni
Job Address: ° 6� `� Ja Permit #
Anv chances to the information provided on this form shall be submitted to the Citv of Cuvertino Build
Department.
t
CITY OF City of Cupertino Building Department
10300 Torre Avenue
CUPS TIN 0 Phone: (408) 777-3228
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner -builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself, you
may protect vourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
if you plan to do your own work, with the exception of various trades that you plan to subcontract, you
should be aware of the following information for your benefit and protection:
if you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is $200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer, you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
security taxes, workers' compensation insurance, disability insurance costs, and unemployment compensation
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law, contact the Internal Revenue
Service (and, if you wish, the U.S. Small Business Administration). For more specific information about your
obligations under state law, contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees, without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner -builder
building permit, erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your community or at 1020 N Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper